Provider First Line Business Practice Location Address:
4035 12TH ST CUT-OFF
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97302-1764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-585-1008
Provider Business Practice Location Address Fax Number:
866-262-1650
Provider Enumeration Date:
11/21/2006